Mouthcare for ELDERS in Residential Care - UBC Geriatric ...
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Mouthcare for ELDERS in Residential Care Second Edition Elders’Elders’ LinkDental Link with with Dental Education, Education, Research, Research, & Service & Service Faculty of Dentistry, University of British Columbia Faculty of Dentistry, University of British Columbia Copyright 2006
INTRODUCTION 1 FORWARD Oral health is an important aspect of the general health and well-being of seniors. With older adults keeping their natural teeth longer than ever before, this updated manual provides an invaluable resource for caregivers to meet the daily oral care needs of seniors. However, there still remains challenges to ensuring seniors, particularly the vulnerable and less mobile, have access to regular oral care. BC’s dentists are committed to developing and implementing solutions in collaboration with key stakeholders, such as dental hygienists, to provide BC’s aging population access to quality oral care services. Dr. Tony Gill, President, BC Dental Association INTRODUCTION Daily mouthcare for people who are frail and dependent is a challenge for dentists, dental hygienists, dental assistants and denturists. It is no less difficult for nurses, care-aides, family members and everyone else who attend to the well-being of others. Ironically, the challenge has increased in direct proportion to the success of public health initiatives that preserve natural teeth. Today, most people have natural teeth, frequently supported by dentures and occasionally with oral implants. Consequently, daily mouthcare has changed from the simple task of rinsing off dentures to the more difficult tasks of removing sticky microbial plaque from natural teeth, and identifying early signs of disease that threaten general health and quality of life. This manual is for care-aides and others who attend to and/or supervise the daily care of frail elders. It explains and illustrates the essentials of oral hygiene and other mouthcare procedures to reduce the risk of infection and to enhance health, cleanliness and dignity in old age. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
GETTING STARTED 2 WHY SHOULD THE MOUTH BE CLEANED EVERY DAY? Plaque forms as a sticky film of harmful bacteria on teeth, on the lining of the mouth and on dentures. Some bacteria produce poisons that cause bleeding gums and bad breath. When the bacteria in plaque are fed sugar from candies, sweet drinks or other soft carbohydrates, they produce acids that cause cavities in teeth. Plaque should be cleaned from the mouth every day to prevent tooth decay, bleeding gums and bad breath. SUGAR Sucrose in the form of refined sugar and carbohydrates negatively affects oral health. Sweets (cakes, cookies, candies), soft drinks and fruit juices can be particularly damaging to teeth because of high sugar content. The sugar is turned into acid by bacteria on the teeth, and if the acid is not neutralized quickly or the bacteria removed, they will create cavities. It takes about 40 minutes to neutralize the acid after consuming a sweet drink or snack, therefore sugar consumption between meals is particularly destructive. ROLE OF THE CAREGIVER Persons in residential care should be encouraged as much as possible to attend to their own mouthcare. Only rarely will residents complain about their mouthcare. Toothbrushing is a more complicated task than dressing. If residents have limited dexterity, poor eyesight, dementia or depression, they may require help with daily mouthcare. Personal neglect should be suspected if there has been a break in the daily mouthcare routine or a change in eating habits, and more particularly if the teeth or dentures trap food, or if the resident has bad breath. When a problem is suspected, it is best to offer assistance with mouthcare. If the gums bleed easily, it probably means that the teeth need to be brushed more frequently and extensively to remove plaque that sticks to tooth surfaces. Ask the resident occasionally if they are suffering from toothaches or mouth discomfort. If a problem is found or suspected, bring it to the attention of a dental professional so that it can be diagnosed and treated appropriately (see page 13). Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
DAILY MOUTHCARE 3 REMOVING PLAQUE The usual tools for cleaning the mouth are toothbrushes (manual or electric), toothpaste and, if possible, dental floss (see page 14). Only effective mouthcare (brushing and flossing) will remove sticky plaque. Rinsing with a mouthwash may reduce the harmful effects of the bacteria but it will not remove plaque. However mouthwash with fluoride can prevent tooth decay. Dentures should be removed before brushing the teeth and they should also be brushed thoroughly every day. It is wise to clean them over a sink full of water to prevent breakage if the denture is accidentally dropped. A good light and a little practise manipulating the lips, cheeks and tongue will improve access around the mouth to see that the plaque is being removed. A tongue depressor can be used to keep the tongue or cheeks out of the way when cleaning the back teeth. It is best to clean the mouth just before the resident goes to bed. This will decrease the exposure of the teeth and gums to the plaque bacteria overnight when the natural protective flow of saliva decreases. To prevent the spread of infection, disposable gloves should be worn when cleaning the mouth. Toothbrushes should never be shared among residents! Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
POSITION THE RESIDENT 4 Correct posture is important for access to the mouth, for comfort of the resident’s head and neck, and for protecting the caregiver’s back. Access to the mouth of a resident in a wheelchair can be obtained by standing behind the resident to support the head and neck. When the resident is lying down, it may be more comfortable for the caregiver if the resident is approached from above and behind or from the side after adjusting the height of the bed. You may have to experiment to find a position that is comfortable for both you and the resident. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
TOOTH CLEANING 5 Rinse the toothbrush with warm water and place a small amount of toothpaste on the bristles. Place the bristles of the brush on the tooth and massage back and forth to remove the plaque from all the surfaces. Plaque tends to collect on the roots of teeth along the gum line. Therefore, it is important to brush both teeth and gums. Move around the mouth in sequence, to contact all of the teeth. Finally, rinse the mouth with water. A moistened cotton gauze can be used to wipe the mouth if a resident cannot spit. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
FLOSSING 6 Floss comes in many forms (unwaxed, waxed and yarn). Select the one that works best for you and the resident. Take a 40-50 cm piece of floss; wind it around the middle fingers of each hand. Control with index fingers or thumb 5 cm of floss so that it can pass comfortably and flexibly between the teeth. The plaque is removed by moving the floss up and down against the surfaces of each tooth. Make sure each “in-between” surface of the teeth is flossed, and that the floss passes up and down, cleaning the tooth’s surface. Floss should not be shared and should be thrown away after each use. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
SPECIAL AIDS 7 INTERPROXIMAL BRUSHES Interproximal brushes are small brushes used to clean the surfaces between teeth. Insert the brush between teeth, and clean with an in-and- out motion. The brushes do wear out so they must be replaced, but they can be rinsed off and reused when still in good shape. FLOSS HOLDERS The addition of a handle may make it easier for people to floss. There are several designs, some with disposable heads and others with spools of floss. Use the floss holder in a similar manner to finger flossing. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
GUM CLEANING 8 The gum around teeth or under dentures should be cleaned with a brush every day. A toothbrush moistened with water can be used to massage the gums, the roof of the mouth and the tongue. This action removes food debris, improves blood circulation and prevents bad breath. Rinsing with water or mouthwash does not clean the mouth adequately. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
DENTURE CLEANING 9 The dentures should be removed from the resident’s mouth and brushed thoroughly at least once a day. Cleaning the inside surface of the denture is very important! Brush the dentures over a sink filled with water to prevent damage if the denture is accidentally dropped. In addition, dentures should be rinsed after each meal to remove food remnants. A clean denture is more easily tolerated by the resident and is more healthy. A toothbrush will remove plaque and food remnants effectively from dentures, teeth and the soft lining of the mouth. A soft toothbrush, denture brush, or a new nailbrush can be used with liquid soap and warm water to brush all surfaces of the denture. Avoid abrasive cleansers, including toothpaste, that can roughen the polished surface of the denture. Usually it is better not to wear dentures while sleeping. However some residents prefer to wear their dentures day and night. If this is the case, special care is needed to ensure that the area under and around the dentures is kept very clean. Dentures should be dry when not in the mouth and stored in a container with the resident’s name. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
SPECIAL CARE 10 BLEEDING GUMS Inflammation of the gums (gingivitis) occurs usually because mouthcare has not removed sticky plaque from the teeth. If plaque is not removed daily, the gums will continue to bleed. Daily tooth brushing must continue even when the gums bleed. If the bleeding persists without improvement for more than a week, contact a dental professional (see page 13). RESISTANT RESIDENTS Resistant behaviour may be a sign that the resident is in pain, especially if the behaviour is unusual. For a resident who clenches or who refuses to open the mouth, the outer surfaces of the front teeth can be cleaned by parting the lips with gentle but firm pressure. Brush some of the teeth each day so that the resident will be encouraged to cooperate. Select a time of day when the resident is most agreeable. What does not work one day may work on another day. AVOIDING BITES Attention is needed if a resident seems uncooperative or anxious. Biting may be an indirect way of expressing a desire to be left alone! It may be preferable to postpone mouthcare until the resident is more relaxed. In any event, never place your fingers between the upper and lower teeth. A mouth prop can be placed between the teeth if the resident is unable to keep the mouth open. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
SPECIAL CARE 11 CARING FOR A DRY MOUTH Saliva plays a vital role in keeping the teeth, gums and lining of the mouth healthy. There are many medications that will reduce the flow of saliva. The attending physician and dentist should be advised if the resident appears to have a particularly dry mouth. In the event that dryness of the mouth persists, there are a few precautions that must be taken to prevent tooth decay and to ease discomfort. The resident should avoid all foods and drinks containing sugar and they should use a mouthrinse with fluoride every day. Under no circumstances should a resident continuously sip a sweetened drink to moisten a dry mouth because of the extreme risk of tooth decay. Use a fluoride containing toothpaste to clean the residents’s teeth at least once a day. Lubricate dry lips during mouthcare to reduce discomfort and further cracking. Avoid using products containing alcohol, lemon or glycerin, as they make a dry mouth even drier. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
SPECIAL CARE 12 UNCONSCIOUS RESIDENT Special precautions should be taken to keep the mouth open and to prevent the resident from choking while cleaning the mouth. To keep the mouth open, use a mouth prop. There are several commercial mouth props available, and they can be washed in the dishwasher and reused. You can make a mouth prop by placing two or three wooden tongue blades together. Wrap several 2 x 2 gauze squares around the top half and secure the gauze in place with tape. Lubricate dry lips to prevent cracking when the mouth is propped open. Turn the head to the side and place the prop in the mouth on the side closest to the pillow to allow access to the other side of the mouth. To prevent choking, allow the resident to lie sideways so that saliva and other fluids will flow out of the mouth. Use suction if available and cottons swabs or towels to control the fluids. Clean the side of the mouth that is not resting on the pillow. Reposition the resident and clean the other side of the mouth. Soak up excess moisture with gauze or a towel. Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
MOUTHCARE DECISIONS FOR CAREAIDS 13 DAILY ORAL INSPECTION NO CONCERNS CONCERNS BLEEDING STOPS BLEEDING GUMS OTHER CONCERNS perform daily mouth pain, bad breath, cleaning for one week broken teeth, refusing mouthcare, change in eating habits BLEEDING CONTINUES RECORD & REPORT REFER TO CONTINUE WITH DAILY MOUTH CARE ORAL HEALTH PROFESSIONAL Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
MOUTHCARE PRODUCTS 14 MOUTH CARE SUPPLIES Soft-bristled toothbrush ADDITIONAL AIDS Fluoride containing toothpaste Interproximal brushes Denture brush Floss holders Disposable gloves Electric toothbrushes Lip lubricant Fluoride mouthrinse Washcloth Mouth moisturizer Glass of water (and straw) Small emesis basin Denture cup STORAGE All mouthcare products for each resident (toothbrushes, toothpaste, mouthrinse, denture cups) should be stored separately in a designated area that is appropriately labelled and visible. Toothbrushes and denture brushes should be labelled, dated and stored upright (e.g., in a cup). Toothbrushes should be changed every 3 months and after upper respiratory infections. DENTAL PRODUCT SUPPLIERS Biotene Johnson & Johnson 1-800-922-5856 www.jnj.com ����������� www.biotene.net (Oralbalance mouth moisturizer) Colgate-Palmolive Canada Inc. Oral B Laboratories 1-800-268-6757 www.oralb.com www.colgate.ca E-Z Floss Specialized Care Co. 1-800-227-0208 1-800-722-7375 www.e-zfloss.com www.specializedcare.com The John O. Butler Company Waterpik technologies Inc. www.jbutler.com www.waterpik.com Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
CREDITS 15 Authors Chris Wyatt, BSc, DMD, MSc, FRCD(C). Michael MacEntee, LDS, Dip Pros, FRCD(C), PhD. Funding Provided By Faculty of Dentistry University of British Columbia, 2199 Wesbrook Mall, Vancouver, BC V6T 1Z3 tel: (604) 822-3564 fax: (604) 822-3562 British Columbia Dental Association Suite 400 – 1765 West 8th Avenue Vancouver, BC V6J 5C6 tel: (604) 736-7202 fax: (604) 736-7588 The College of Dental Hygienists of British Columbia Suite 219, Yarrow Building, 645 Fort Street Victoria, BC V8W 1G2 tel: (250) 383-4101 fax: (250) 383-4144 1-800-778-8277 Toll Free within BC www.cdhbc.com Ministry of Health Ministry of Employment and Income Assistance www.gov.bc.ca Acknowledgments We wish to thank Anne-Marie Skolaude for organizing the content and images of this manual. Also we thank the following for reviewing the educational material: UBC Geriatric Dentistry Program dental hygienists Leeane Donnelly, RDH, BDSC, MSc Ashif Dharamsi, RDH, ID Shafik Dharamsi, RDH, PhD Janice Williams, RDH, BSc Elders’ Link with Dental Education, Research, & Service Faculty of Dentistry, University of British Columbia
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